Rich Daly, HFMA Senior Writer/Editor

No legislation to provide such funding has yet advanced.

May 31—Policy watchers from across the political spectrum agreed that several steps are needed to quickly stabilize the government-run health insurance marketplaces for 2018.

Congress needs to “immediately” advance legislation to ensure payment of out-of-pocket subsidies that were promised but not funded by the Affordable Care Act (ACA), said Brian Webb, assistant director for Health Policy and Legislation for the National Association of Insurance Commissioners.

So-called cost-sharing reduction (CSR) payments were authorized for ACA marketplace enrollees with incomes of up to 250 percent of the federal poverty level, but the House of Representatives successfully challenged the payments as illegal unless appropriated by Congress. The Trump
administration and House Republicans recently asked an appeals court for a 90-day hold on the lawsuit, which some interpreted as a sign that legislation is coming to address the issue, according to news reports.

“Do it right now—pass it,” Webb said of the CSR funding.

Sabrina Corlette, JD, a professor at the Center on Health Insurance Reforms at Georgetown University and an ACA advocate, agreed that the CSR funding is needed “tomorrow.”

Nearly 200 House Democrats recently demanded that President Trump fund the CSR payments, and some Republicans have voiced support for such legislation. But no legislation to provide the funding has advanced.

The lack of such funding could lead some insurers to drop out and others to sharply increase the premiums of their ACA plans, some industry advisers have warned.

For instance, in requesting a 23 percent increase for 2018, Blue Cross and Blue Shield of North Carolina noted that it did not expect the federal government to end up providing the CSR payments. Only an 8.8 percent increase would be needed, the insurer said, if Congress and the Trump administration
guaranteed CSR payments for all of 2018.

America’s Health Insurance Plans (AHIP), the largest health insurer trade group, agreed that the CSR payments are key—at least through 2019. A recent AHIP
letter to the senior Senate Republican on health policy, Sen. Orrin Hatch (R-Utah), estimated that the loss of CSRs would drive a premium increase of 15 to 20 percent for ACA marketplace plans and create a need for higher federal premium subsidies.

“Even more important, without CSR funding certainty, it will lead to fewer, if any, plan choices for millions of consumers,” wrote Marilyn Tavenner, president and CEO of AHIP.

Tavenner noted that the deadline for plans sold through the federally operated ACA marketplace to submit their initial rate plans to the Centers for Medicare & Medicaid Services is June 21. However, filing deadlines have passed in several states and are looming in 11 other states.

Reinsurance Help

Congress also needs to quickly enact legislation to create a reinsurance program for the ACA marketplaces, Webb and Corlette said during a policy discussion at the Bipartisan Policy Center.

“I haven’t heard anybody say there is anything better than a good reinsurance program,” said Joel Ario, a managing director of Manatt Health Solutions who oversaw the marketplaces for the Obama administration.

Ario praised the stability fund provision of the American Health Care Act (AHCA), a partial ACA repeal bill that passed the House on May 4 and is under consideration in the Senate. The bill’s stability fund would provide $15 billion in both 2018 and 2019 for states to stabilize their
insurance markets and then provide $10 billion annually from 2020 through 2026.

“If they just pass the stability fund over there and leave the rest of it out, we’d be in pretty good shape,” Ario said.

A $15 billion annual reinsurance fund could reduce marketplace plan premiums by 15 percent or more and simultaneously lower federal spending on premium assistance, according to AHIP.

J. Bradley Wilson, president and CEO of Blue Cross and Blue Shield of North Carolina, urged Congress to enact the reinsurance program as part of a bipartisan package so that insurers would know it will exist at least through 2019.

Individual Mandate

Among the immediate policy actions advocated by Mila Kofman, executive director of Washington, D.C.’s ACA marketplace, and others was better enforcement of the ACA’s individual mandate.

“The individual mandate is a perfectly horrible solution except for all of the alternatives,” Corlette said.

The nonpartisan Congressional Budget Office (CBO) somewhat agreed. CBO noted in its latest
evaluation of the AHCA that the ACA marketplaces should function “in most areas” if the subsidies and the mandate continue.

“The subsidies to purchase coverage, combined with the effects of the individual mandate, which requires most individuals to obtain insurance or pay a penalty, are anticipated to cause sufficient demand for insurance by enough people, including people with low health care expenditures,
for the market to be stable in most areas,” CBO officials wrote.

The CBO cited the repeal of the individual mandate—not the loss of subsidies—as a leading reason why millions fewer would be covered under the AHCA.

But the mandate doesn’t work unless the penalties are high enough and are enforced, said Alice Rivlin, co-chair of the Debt Reduction Task Force at the Bipartisan Policy Center.

AHIP stopped short of urging continuation of the mandate and instead noted that if the mandate is eliminated, alternatives will be needed to incentivize continuous coverage.

Although the AHCA would end the mandate, Republicans have suggested alternatives such as imposing a premium penalty on those who let their coverage lapse or auto-enrolling people into low-cost high-deductible health plans.

The use of auto-enrollment would be very challenging logistically due to the churn that occurs in the individual marketplace, Corlette said.

Alternatively, Congress could increase enrollment of so-called young invincibles by increasing the premium subsidies that are available to people for whom that cost may be a barrier to coverage, Kofman said.

“If I can only afford $100 and my premium reduction is not sufficient, then I’m going to sit out if I am healthy,” Kofman said.

One industry adviser emphasized the overarching need for predictability.

“Whatever you are going to do with CSRs, whatever you are going to do with the mandate, do it right now and then stay with it,” Ario said. “At the end of the day, just tell us where it is and promise us you’re not going to keep fine-tuning it for the next two years.”

No legislation to provide such funding has yet advanced.

May 31—Policy watchers from across the political spectrum agreed that several steps are needed to quickly stabilize the government-run health insurance marketplaces for 2018.

Congress needs to “immediately” advance legislation to ensure payment of out-of-pocket subsidies that were promised but not funded by the Affordable Care Act (ACA), said Brian Webb, assistant director for Health Policy and Legislation for the National Association of Insurance Commissioners.

So-called cost-sharing reduction (CSR) payments were authorized for ACA marketplace enrollees with incomes of up to 250 percent of the federal poverty level, but the House of Representatives successfully challenged the payments as illegal unless appropriated by Congress. The Trump
administration and House Republicans recently asked an appeals court for a 90-day hold on the lawsuit, which some interpreted as a sign that legislation is coming to address the issue, according to news reports.

“Do it right now—pass it,” Webb said of the CSR funding.

Sabrina Corlette, JD, a professor at the Center on Health Insurance Reforms at Georgetown University and an ACA advocate, agreed that the CSR funding is needed “tomorrow.”

Nearly 200 House Democrats recently demanded that President Trump fund the CSR payments, and some Republicans have voiced support for such legislation. But no legislation to provide the funding has advanced.

The lack of such funding could lead some insurers to drop out and others to sharply increase the premiums of their ACA plans, some industry advisers have warned.

For instance, in requesting a 23 percent increase for 2018, Blue Cross and Blue Shield of North Carolina noted that it did not expect the federal government to end up providing the CSR payments. Only an 8.8 percent increase would be needed, the insurer said, if Congress and the Trump administration
guaranteed CSR payments for all of 2018.

America’s Health Insurance Plans (AHIP), the largest health insurer trade group, agreed that the CSR payments are key—at least through 2019. A recent AHIP
letter to the senior Senate Republican on health policy, Sen. Orrin Hatch (R-Utah), estimated that the loss of CSRs would drive a premium increase of 15 to 20 percent for ACA marketplace plans and create a need for higher federal premium subsidies.

“Even more important, without CSR funding certainty, it will lead to fewer, if any, plan choices for millions of consumers,” wrote Marilyn Tavenner, president and CEO of AHIP.

Tavenner noted that the deadline for plans sold through the federally operated ACA marketplace to submit their initial rate plans to the Centers for Medicare & Medicaid Services is June 21. However, filing deadlines have passed in several states and are looming in 11 other states.

Reinsurance Help

Congress also needs to quickly enact legislation to create a reinsurance program for the ACA marketplaces, Webb and Corlette said during a policy discussion at the Bipartisan Policy Center.

“I haven’t heard anybody say there is anything better than a good reinsurance program,” said Joel Ario, a managing director of Manatt Health Solutions who oversaw the marketplaces for the Obama administration.

Ario praised the stability fund provision of the American Health Care Act (AHCA), a partial ACA repeal bill that passed the House on May 4 and is under consideration in the Senate. The bill’s stability fund would provide $15 billion in both 2018 and 2019 for states to stabilize their
insurance markets and then provide $10 billion annually from 2020 through 2026.

“If they just pass the stability fund over there and leave the rest of it out, we’d be in pretty good shape,” Ario said.

A $15 billion annual reinsurance fund could reduce marketplace plan premiums by 15 percent or more and simultaneously lower federal spending on premium assistance, according to AHIP.

J. Bradley Wilson, president and CEO of Blue Cross and Blue Shield of North Carolina, urged Congress to enact the reinsurance program as part of a bipartisan package so that insurers would know it will exist at least through 2019.

Individual Mandate

Among the immediate policy actions advocated by Mila Kofman, executive director of Washington, D.C.’s ACA marketplace, and others was better enforcement of the ACA’s individual mandate.

“The individual mandate is a perfectly horrible solution except for all of the alternatives,” Corlette said.

The nonpartisan Congressional Budget Office (CBO) somewhat agreed. CBO noted in its latest
evaluation of the AHCA that the ACA marketplaces should function “in most areas” if the subsidies and the mandate continue.

“The subsidies to purchase coverage, combined with the effects of the individual mandate, which requires most individuals to obtain insurance or pay a penalty, are anticipated to cause sufficient demand for insurance by enough people, including people with low health care expenditures,
for the market to be stable in most areas,” CBO officials wrote.

The CBO cited the repeal of the individual mandate—not the loss of subsidies—as a leading reason why millions fewer would be covered under the AHCA.

But the mandate doesn’t work unless the penalties are high enough and are enforced, said Alice Rivlin, co-chair of the Debt Reduction Task Force at the Bipartisan Policy Center.

AHIP stopped short of urging continuation of the mandate and instead noted that if the mandate is eliminated, alternatives will be needed to incentivize continuous coverage.

Although the AHCA would end the mandate, Republicans have suggested alternatives such as imposing a premium penalty on those who let their coverage lapse or auto-enrolling people into low-cost high-deductible health plans.

The use of auto-enrollment would be very challenging logistically due to the churn that occurs in the individual marketplace, Corlette said.

Alternatively, Congress could increase enrollment of so-called young invincibles by increasing the premium subsidies that are available to people for whom that cost may be a barrier to coverage, Kofman said.

“If I can only afford $100 and my premium reduction is not sufficient, then I’m going to sit out if I am healthy,” Kofman said.

One industry adviser emphasized the overarching need for predictability.

“Whatever you are going to do with CSRs, whatever you are going to do with the mandate, do it right now and then stay with it,” Ario said. “At the end of the day, just tell us where it is and promise us you’re not going to keep fine-tuning it for the next two years.”

HFMA RESOURCE LIBRARY

Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.

No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.

This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.

This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.

Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.

Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.

To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.

Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.

Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.

Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.

Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.

The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.

Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.

Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities.
Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.

Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.

Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.

The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.

The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.

Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.

Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.

Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.

Read more about factors contributing to the changes in the post-acute marketplace and what it means for manufacturers, physicians, clinicians, patients, and post-acute facilities as they anticipate the transition to the second curve.

HSG helped the physicians and executives of St. Claire Regional in Morehead, Kentucky, define their shared vision for how the group would evolve over the next decade. As well as, develop the strategic and operational priorities which refocused and accelerated the group’s evolution.

The client was a nine-hospital health system with 14 clinics serving communities in a multi-state market with very limited access to care, poor economic conditions, high unemployment, and a heavy Medicare/Medicaid/uninsured payer mix. In most of these communities, the system was the sole source of care.
Though the clinics were of substantial size (they employed 98 physicians) and comprised of multiple specialists, the physicians functioned as individuals and the practices lacked any real group culture.

Clinical integration can be expensive, but it doesn’t have to be, as this four-step road map for developing a CIN proves. Does it have to cost millions to initiate a clinical integration strategy?
Contrary to popular belief, we have clients who have generated substantial shared savings and a significant ROI over time, without massive investments. Yes, some financial capital is required for resources the CIN providers can’t bring to the table themselves. But the size of that investment can be miniscule relative to the value it produces: improved outcomes and documentation for payers.

Today’s concerns about physician compensation are the result of the changing healthcare environment. The transition to value is slow, but finally becoming a reality. Proactive hospitals want to ensure that provider incentives are properly aligned with ever-increasing value-based demands.
This report focuses on the three big questions HSG receives about adding value to physician compensation; Why are organizations redesigning their provider compensation plans? What elements and parameters must be part of successful compensation plans? How are organizations implementing compensation changes?

Revenue Cycle Management has become an even more complex issue with declining reimbursements, implementation of Electronic Health Records, evolving local carrier determinations (LCD), and payer credentialing [The emphasis on healthcare fraud, abuse and compliance has increased the importance of accuracy of data reporting and claims filing).
The efficiency of a medical practice’s billing operations has critical impact on the financial performance. In many cases, patient billings are the primary revenue source that pays staff salaries, provider compensation and overhead operating cost. Inefficiencies or inaccurate billing will contribute to operating losses.

This publication identifies and outlines the necessary characteristics of a fully-functioning clinically integrated network (CIN). What it doesn’t do is detail how hospitals and providers can participate in the value-based care environment during the development process.
One common misconception is that the CIN can’t do anything significant until it has obtained the FTC’s “clinically integrated” stamp of approval. While the network must satisfy the FTC’s definition of clinical integration before single signature contracting for FFS rates and contracts can legally start, hospitals and providers can enjoy three key benefits during the development process.

Nearly half of all Medicare beneficiaries treated in the hospital will need post-acute care services after discharge. For these patients, a stay in an inpatient rehabilitation facility, skilled nursing facility or other post-acute care setting comes between hospital and home.

With the proper process, tools, and feedback mechanisms in place, budgeting can be a valuable exercise for organizations while helping hold organizational leaders accountable. Having a proper monthly variance review process is one of the most critical factors in creating a more efficient and accurate budget. Monthly variance reporting puts parameters around what is to be expected during the upcoming budget entry process.

Managing the cost of patient care is the top strategic priority of most hospital CFOs today. As healthcare shifts to more data-driven decision making, having clear visibility into key volume, cost and profitability measures across clinical service lines is becoming increasingly important for both long-range and tactical planning activities. In turn, the cost accounting function in healthcare provider organizations is becoming an increasingly important and strategic function. This whitepaper includes five strategies for efficient and accurate cost accounting and service line analytics and keys to overcoming the associated challenges.